Provider Demographics
NPI:1225142003
Name:PHILADELPHIA VISION CENTER
Entity Type:Organization
Organization Name:PHILADELPHIA VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:215-568-0700
Mailing Address - Street 1:1100 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3601
Mailing Address - Country:US
Mailing Address - Phone:215-568-0700
Mailing Address - Fax:
Practice Address - Street 1:1100 MARKET ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-3601
Practice Address - Country:US
Practice Address - Phone:215-568-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE006597P152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4961800001Medicare ID - Type Unspecified